Show navigation

Available in:

Audio & Reference Manual
MP3 Download

Medical Record Charting Fundamentals

Learn and understand basic medical record charting fundamentals and the impacts of HIPAA on medical chart access.During this topic we will cover the basics of medical charting, including defining the scope of medical charting, discussing the history and future of EMR, and covering the basic do's and don'ts of charting in both written and EMR format. We will cover charting best practices, including charting methods and tips and tricks designed to protect providers from lawsuits. We will consider the impacts of HIPAA on chart access and chart retention practices, as well as strategies to follow in the event of a violation. We will also discuss examples of how charting is used in litigation, preparing you for tactics used by plaintiff's attorneys in reviewing charting and exploiting gaps in charting.
Purchase Options

More Program Information

Why Lorman?

Over 32 years and 1.4 million customers worth of experience providing continuing education. Our passion is providing you world-class training to help you succeed in business and as a professional.

Agenda

The Elements of a Medical Chart
  • What Is a Medical Chart: Definitions
  • What Is EMR?
  • History of EMR
    • HIPAA / HITECH
Best Practices of Medical Charting
  • Joint Commission Requirements
  • Basic Goals of Documentation
  • Consideration of the Audience
  • Gatekeeper Statutes
  • How to See Documentation as a Defense
  • Beyond the S-O-A-P Note
  • Charting Do's and Don'ts
    • Basics
    • Who Can Add to the Chart
    • How Do You Update or Correct the Chart?
    • Documentation of Emerging Evaluations / Diagnoses
    • EMR Prefills, Check Boxes and Cutting and Pasting
  • Case Examples
    • Uses in Deposition
Communication: Documentation of Contacts With Patient, Family, Staff and Colleagues
  • Communication Matters
  • How to Tell the Story
  • Failure to Follow up by Doctor
  • Documentation of Failures to Return for Care / Follow up by Patient
  • Curbside Consultations
  • New Forms of Communication
    • Emails
    • Text
    • Voicemails and Private Cell Phones
    • Integrated Portals
    • Social Media
    • Do's and Don'ts
How EMR Has Changed Medical Practice
  • Notice
  • Creation of Physician – Patient Relationship
  • Issues
    • Information Overload
    • Issues With Dictation and Review
    • Incompatible Systems
    • Audit Trails
    • GPS Data
    • In Person Document Reviews
HIPAA Issues
  • HIPAA Overview – What Is HIPAA?
  • Impact of HIPAA: Lost Charts / Data Loss
  • Impact of HIPAA: Provider Access
  • How to Respond to a Known or Suspected Breach
Purchase Options

More Program Information

Why Lorman?

Over 32 years and 1.4 million customers worth of experience providing continuing education. Our passion is providing you world-class training to help you succeed in business and as a professional.

Credits

Audio & Reference Manual

This program does NOT qualify, nor meet the National Standard for NASBA accreditation.

MP3 Download

This program does NOT qualify, nor meet the National Standard for NASBA accreditation.

Purchase Options

More Program Information

Why Lorman?

Over 32 years and 1.4 million customers worth of experience providing continuing education. Our passion is providing you world-class training to help you succeed in business and as a professional.

Faculty

Stuart Berman

Stuart Berman

Lowis & Gellen LLP

  • Partner at Lowis & Gellen LLP in Chicago
  • Practice focuses on medical malpractice, long term care defense, and the formation of captive insurance companies; he defends hospitals, medical centers, nursing homes, physician groups, individual physicians and nurses in medical malpractice and long term care negligence cases
  • Has particular expertise in cases involving complex and catastrophic losses, products liability and compliance issues
  • Consults and advises hospitals and other health care facilities on restructuring risk management processes and compliance issues
  • National supervising counsel for two national insurance collectives and is vice-president of captive “incubator” Midwest Consultants, where he works with pending and existing projects, assisting doctors and hospitals in forming captive insurance companies, risk retention groups (RRGs), and risk purchasing groups (RPGs)
  • In addition to his practice as a lawyer, he frequently speaks to medical and legal professionals regarding topics related to health care litigation; he has written or co-written multiple publications and has written, edited, presented and/or co-presented multiple lectures covering a range of topics in medical malpractice
  • Graduate, Chicago-Kent College of Law; undergraduate, Bates College in Lewiston, Maine
Kelly Pachis

Kelly Pachis

Lowis & Gellen LLP

  • Associate attorney at Lowis & Gellen LLP
  • Concentrates her practice in civil litigation with an emphasis on medical malpractice defense, representing hospitals, nursing homes and physicians in various specialties, including internal medicine, obstetrics & gynecology, orthopedic surgery, general surgery, anesthesiology, urology, and neurosurgery
  • Experience in all stages of the litigation process, from depositions to motion practice and trial; she second chaired her first case at trial in May 2013, resulting in a verdict for the defendant neurosurgeon
  • Has been recognized as an Emerging Lawyer by Leading Lawyer Magazine, which recognizes the top 2% of lawyers under 40 years old
  • Admitted to the Illinois Bar in 2011 and to the U.S. District Court for the Northern District of Illinois in 2013; an active member of the Illinois Association of Defense Trial Counsel, Chicago Healthcare Risk Management Society, and The John Marshall Law School Alumni Advisory Board she also serves as Second Vice President of the Bohemian Lawyers’ Association of Chicago
  • J.D. degree, The John Marshall Law School; B.A. degree, with honors, with a major in journalism and a minor in political science, University of Iowa
Patrick Viktora

Patrick Viktora

Lowis & Gellen LLP

  • Associate attorney at Lowis & Gellen LLP
  • Concentrates his practice in civil litigation with an emphasis on medical malpractice defense, representing physicians, nurses, and hospitals in complex litigation
  • Also has experience handling cases involving pharmaceutical liability, premises liability, and claims of physician-patient sexual abuse; in addition to handling all stages of litigation, he also handles pre-suit investigations of potential high risk claims
  • Has been recognized as an Emerging Lawyer by Leading Lawyer Magazine, which recognizes the top 2% of lawyers under 40 years old
  • Admitted to practice in Illinois and is an active member of the Chicago Healthcare Risk Management Society
  • J.D. degree, with a certificate in business law, magna cum laude, DePaul University College of Law; B.A. degree in political science, University of Illinois
Purchase Options

More Program Information

Why Lorman?

Over 32 years and 1.4 million customers worth of experience providing continuing education. Our passion is providing you world-class training to help you succeed in business and as a professional.

All of your training, right here at Lorman.

Pay once and get a full year of unlimited training in any format, any time!

  • Live Webinars
  • OnDemand Webinars
  • MP3 Downloads
  • Course Manuals
  • Audio Recordings*
  • Executive Reports
  • White Papers and Articles
  • Sponsored Live Webinars

Additional benefits include:

  • State Specific Credit Tracker
  • Members Only Newsletter
  • All-Access Pass Course Concierge

* For audio recordings you only pay shipping

Questions? Call 877-296-2169 to speak with a real person.

Sign Up Today
With This Course

Access to all training products for one year
$699/year

Unlimited Lorman Training

With the All-Access Pass there is no guessing what you will need for your yearly training budget. $699 will cover all of your training needs for an entire year!

Easy Registrations

Once you purchase your All-Access Pass you will never be any further than one-click away from attending any Lorman training course.

Invest in Yourself

You haven't gotten to where you are professionally by luck alone; it's taken a lot of hard work and training. Invest in yourself with the All-Access Pass.

Product ID: 406580
Published 2019
Purchase Options

Available in Multiple Formats

Purchase this course and learn on your schedule!